09/11/12 Ask-the-Contractor Teleconference (ACT ... - WPS Medicare
09/11/12 Ask-the-Contractor Teleconference (ACT ... - WPS Medicare
09/11/12 Ask-the-Contractor Teleconference (ACT ... - WPS Medicare
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<strong>09</strong>/<strong>11</strong>/<strong>12</strong> <strong>Ask</strong>-<strong>the</strong>-<strong>Contractor</strong> <strong>Teleconference</strong> (<strong>ACT</strong>) Transcript<br />
Moderator: Mary Muchow<br />
September <strong>11</strong>, 20<strong>12</strong><br />
2:00 pm ET<br />
Operator:<br />
Good afternoon. My name is Angie, and I will be your conference operator<br />
today. At this time, I would like to welcome everyone to <strong>the</strong> J5 <strong>ACT</strong><br />
Conference Call. All lines have been placed on mute in order to prevent any<br />
background noise.<br />
After <strong>the</strong> speakers’ remarks, <strong>the</strong>re will be a question-and-answer session. If<br />
you would like to ask a question at this time, simply press star <strong>the</strong>n <strong>the</strong><br />
number 1 on your telephone keypad. If you would like to withdraw your<br />
question, press <strong>the</strong> pound key. Thank you.<br />
Ms. Muchow, you may begin your conference.<br />
Mary Muchow: Well, good afternoon, everyone. I’d like to welcome you to <strong>the</strong> September <strong>11</strong>,<br />
20<strong>12</strong>, Jurisdiction 5 <strong>Medicare</strong> Part B <strong>Ask</strong>-<strong>the</strong>-<strong>Contractor</strong> <strong>Teleconference</strong> or<br />
<strong>ACT</strong>. My name is Mary Muchow, and I’m speaking to you today from <strong>the</strong><br />
<strong>WPS</strong> <strong>Medicare</strong> Office in Madison, Wisconsin. I represent Part B Provider<br />
Outreach and Education.<br />
On this call today, <strong>the</strong>re are several people from a variety of areas within <strong>the</strong><br />
<strong>Medicare</strong> division. To name a few, we have provider enrollment, <strong>Medicare</strong><br />
internal processes, payment recovery, our policy staff is with us today as is<br />
medical review. A representative from <strong>the</strong> Provider Research Relations<br />
Research Specialists is joining us, as is claims and appeals, and last but not<br />
least, <strong>Medicare</strong> Publications.<br />
These subject matter experts are available during today’s telephone call to<br />
provide education, program updates, to answer your questions and take<br />
feedback. In addition, we will provide necessary follow-up to any issues that<br />
cannot be resolved during today’s teleconference.<br />
This particular teleconference is specific to Iowa, Kansas, Missouri, and<br />
Nebraska providers that submit claims to <strong>Medicare</strong> Part B. We don’t have<br />
anyone on this call today to address any Part A concerns. However, Part A<br />
does host a number of teleconferences throughout <strong>the</strong> year. I encourage you<br />
to take a look at our Part A J5 Training Program’s web page to choose a<br />
teleconference that would best fit your Part A need. The action to choose that<br />
web page will show up on <strong>the</strong> sub menu that drops down when you hover<br />
over <strong>the</strong> Training tab that appears on <strong>the</strong> primary navigation bar on <strong>the</strong> Part A<br />
J5 website.<br />
Created 10/02/20<strong>12</strong> 1<br />
http://www.wpsmedicare.com/
As you may be aware, providers may submit suggestions or topics on <strong>the</strong><br />
<strong>ACT</strong> advance http://www.wpsmedicare.com<br />
request form and that’s available on our website. The form<br />
should be filled out in its entirety and should include what specific information<br />
that you’re looking for. The completed form can <strong>the</strong>n be faxed or e-mailed to<br />
<strong>WPS</strong> <strong>Medicare</strong>. The fax number and <strong>the</strong> e-mail address both appear on <strong>the</strong><br />
form itself.<br />
Now <strong>the</strong> existing form is being updated and will soon reflect a new fax<br />
number to which <strong>the</strong> form may be faxed. Please be certain that you discard<br />
any old forms that you may have in your possession. The new fax number will<br />
be on <strong>the</strong> form itself as I previously mentioned. That particular new fax<br />
number is (618) 998-5249.<br />
Now please keep in mind that if your request is not received by <strong>WPS</strong><br />
<strong>Medicare</strong> at least five days prior or in advance of <strong>the</strong> call date, we may not be<br />
able to address your request during <strong>the</strong> <strong>ACT</strong>. These five days allow time to<br />
consult with subject matter experts here at <strong>WPS</strong> <strong>Medicare</strong> and it allows us to<br />
research those requests that are complex in nature.<br />
Now remember that <strong>ACT</strong>s are designed for general inquiries, not claim<br />
specific information. If you have a claim specific issue, please contact <strong>WPS</strong><br />
<strong>Medicare</strong> Customer Service as <strong>the</strong>y are best equipped to help you.<br />
To begin today’s <strong>ACT</strong>, we will address <strong>the</strong> advance requests that have been<br />
received and after that, we’ll ask Angie to open up <strong>the</strong> lines to our questions<br />
from all of you, our participants. We will do our best to answer all of <strong>the</strong><br />
questions while we are on <strong>the</strong> telephone call today. However, we may need<br />
additional time to research additional questions or issues that are complex in<br />
nature. If this occurs, we’ll ask you for your name and your telephone<br />
number, and someone will get back to you within <strong>the</strong> next couple of business<br />
days.<br />
Today’s teleconference of this <strong>ACT</strong> is being recorded. If this causes an issue<br />
for anyone, you might wish to keep this in mind during <strong>the</strong> question-andanswer<br />
period. You can access a recording and a transcription of this J5 <strong>ACT</strong><br />
on our J5 On Demand Training web page in approximately two weeks from<br />
this call date.<br />
Our first advance question today received from Karen states, “Some of our<br />
physicians would like to start giving <strong>the</strong> influenza vaccine to patients. What is<br />
<strong>the</strong> coverage period for this service during flu season For example, is it<br />
October through May”<br />
The Centers for <strong>Medicare</strong> & Medicaid Services, or CMS, currently follows <strong>the</strong><br />
Centers for Disease Control and Prevention, or CDC’s recommendation that<br />
<strong>the</strong> flu season begins as soon as <strong>the</strong> vaccine is available and continues<br />
through <strong>the</strong> flu season. CMS concurs with <strong>the</strong> CDC that <strong>the</strong> beginning and<br />
duration of <strong>the</strong> flu season cannot be precisely determined.<br />
Just as one of our current messages on our provider home page states on<br />
our website, “We do receive numerous phone calls this time of year asking us<br />
2
for a new pricing on <strong>the</strong> influenza vaccine.” We will not have that information<br />
prior to notification http://www.wpsmedicare.com<br />
by CMS. When we receive that information from CMS, we<br />
will publish that information or that notice in <strong>the</strong> <strong>WPS</strong> <strong>Medicare</strong> eNews.<br />
Please continue to watch eNews for this notification. Once available, <strong>the</strong><br />
CMS website will actually contain <strong>the</strong> pricing. It will be posted out on <strong>the</strong> CMS<br />
website. That website location will be included in <strong>the</strong> eNews that is sent out<br />
by <strong>WPS</strong> <strong>Medicare</strong>.<br />
If you do not subscribe to eNews, we encourage you to sign up. Our listserv<br />
subscribers are assured that <strong>the</strong>y receive <strong>the</strong> most current <strong>WPS</strong> <strong>Medicare</strong><br />
information in <strong>the</strong> most expeditious manner. Now, to sign up for our eNews or<br />
to manage your current eNews subscription, simply choose eNews, which<br />
appears in <strong>the</strong> upper right-hand corner of each <strong>WPS</strong> <strong>Medicare</strong> web page.<br />
Here’s a question we received from Amy: “Can an Advanced Registered<br />
Nurse Practitioner, ARNP, supervise a registered nurse performing a stress<br />
test This would be reported with CPT code 93015 and bill that service under<br />
<strong>the</strong> ARNP’s or <strong>the</strong> Advanced Registered Nurse Practitioner’s provider<br />
number.”<br />
And <strong>the</strong> answer to that is this, <strong>the</strong> Code of Federal Regulations requires that<br />
diagnostic tests covered by <strong>the</strong> Social Security Act and payable under <strong>the</strong><br />
physician fee schedule with certain exceptions that are listed in <strong>the</strong><br />
regulations has to be performed under <strong>the</strong> supervision of an individual<br />
meeting <strong>the</strong> definition of a physician as listed in <strong>the</strong> Social Security Act.<br />
It goes on to say that non-physician practitioners cannot act as supervisory<br />
physicians under <strong>the</strong> diagnostic test benefit. You can find this information in<br />
<strong>the</strong> CMS <strong>Medicare</strong> Benefit Policy Manual. That’s publication 100-02 Chapter<br />
15 Section 80. Remember you can easily access CMS’ Internet-Only Manual<br />
by choosing <strong>the</strong> link labeled Manual. It appears under <strong>the</strong> top five links<br />
heading on <strong>the</strong> center right portion of <strong>the</strong> CMS home page. It’s available at<br />
www.cms.gov.<br />
Our third and last Advance Request for today’s call states, “Recently, a CMS<br />
review on a denial suggested that <strong>the</strong> technical and professional component<br />
on a procedure should reflect different dates if <strong>the</strong>y were performed on a<br />
different date. The request fur<strong>the</strong>r states this is not currently <strong>the</strong> procedure of<br />
any practice in any CMS region in <strong>the</strong> country. Is this a new regulation And if<br />
so, please indicate where this can be found in <strong>the</strong> existing claims manual.<br />
Fur<strong>the</strong>r, <strong>the</strong> request we received states, it is widely known that a professional<br />
component may be performed at a later time when <strong>the</strong> original technical<br />
component of <strong>the</strong> procedure was performed. The professional component<br />
report reflects <strong>the</strong> date <strong>the</strong> test was done and <strong>the</strong> date <strong>the</strong> test was read. It<br />
has always been <strong>the</strong> understanding of <strong>the</strong> physician communities that <strong>the</strong><br />
dates of <strong>the</strong> technical component and <strong>the</strong> professional component need to be<br />
identical in order to be paid. If this is not correct, <strong>the</strong>n <strong>the</strong>re has been a<br />
terrible miscommunication for years because this is <strong>the</strong> usual practice of all<br />
physicians.”<br />
3
Thank you, Paula, for submitting this request. This provides <strong>WPS</strong> <strong>Medicare</strong> a<br />
perfect opportunity http://www.wpsmedicare.com<br />
to address this question that does indeed come up very,<br />
very often. <strong>WPS</strong> <strong>Medicare</strong> has always instructed that <strong>the</strong> date of service must<br />
reflect <strong>the</strong> date that <strong>the</strong> provider actually performed <strong>the</strong> service. For services<br />
with professional and technical components, <strong>the</strong> date of service could be<br />
different depending on when <strong>the</strong> interpretation is performed.<br />
This is <strong>the</strong> same message that <strong>WPS</strong> <strong>Medicare</strong> has always given to providers.<br />
Our message has never changed. The CMS Internet-Only Manual is<br />
Publication 100-04, <strong>the</strong> <strong>Medicare</strong> Claims Processing Manual in Chapter 26,<br />
which is entitled "Completing and Processing Form CMS-1500 Data," it’s<br />
actually Section 10, includes instructions for completing <strong>the</strong> <strong>Medicare</strong> claim.<br />
Instructions for completion of Item 24A or <strong>the</strong> electronic equivalent, if you<br />
submit claims electronically, specifically states, “Enter a six-digit or eight-digit<br />
date for each procedure, service, or supply.”<br />
Item 24D instructions inform <strong>the</strong> provider to enter <strong>the</strong> procedure, service, or<br />
supply using <strong>the</strong> CMS Healthcare Common Procedure Coding System or<br />
HCPCS code, and when applicable, show <strong>the</strong> HCPCS code modifiers along<br />
with that HCPCS code. So based on <strong>the</strong> CMS claim form instructions found in<br />
publication 100-04, a provider who performs <strong>the</strong> professional component of a<br />
service will list <strong>the</strong> date that he or she performed <strong>the</strong> service in Item 24A or<br />
<strong>the</strong> electronic equivalent and will report <strong>the</strong> appropriate HCPCS code and <strong>the</strong><br />
PC modifier in Item 24D.<br />
At this time, I’d like to invite Angie to once again inform participants how <strong>the</strong>y<br />
may post <strong>the</strong>ir questions.<br />
Operator:<br />
If you would like to ask an audio question, please press star 1 on your<br />
telephone keypad. We’ll pause for just a moment to compile <strong>the</strong> Q&A roster.<br />
Your first question comes from <strong>the</strong> line of Barb Carter.<br />
Mary Muchow:<br />
Barb Carter:<br />
Mary Muchow:<br />
Hi, Barb.<br />
Hello. We have a question. We are getting denials on our lesions, on one of<br />
<strong>the</strong> codes on <strong>the</strong> lesions that does <strong>the</strong> related or qualifying claim or service<br />
was not identified on this claim and we need help to solve that.<br />
That is a claim-specific denial. And what you’re going to need to do with that<br />
is call customer service. They are better equipped to help you. Those of us<br />
that have assembled for this call, we’d love to help you, but unfortunately, we<br />
don’t have any system access. We can’t look at your claim and look at <strong>the</strong><br />
o<strong>the</strong>r claim that pended up against it to let us know additional information and<br />
to provide additional information on why your claim denied.<br />
So if you’ll give customer service a call, <strong>the</strong>y’ll be happy to assist you.<br />
Barb Carter:<br />
OK, thank you.<br />
4
Mary Muchow:<br />
Operator:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
You’re welcome.<br />
http://www.wpsmedicare.com<br />
Your next question comes from <strong>the</strong> line of Amy Green.<br />
Hello, Amy.<br />
Hi. How are you<br />
I’m doing fine, thank you.<br />
First, I have three questions, so I assume you probably want me to get in and<br />
request <strong>the</strong>m after this. The first question has to do with <strong>the</strong> ARNP<br />
supervising an RN. I got <strong>the</strong> information what manual it was in but I did not<br />
catch <strong>the</strong> chapter when you’re answering <strong>the</strong> Q&A, where you can find this<br />
information.<br />
OK. I’m just looking back through my notes, Amy. It is actually information in<br />
<strong>the</strong> <strong>Medicare</strong> Benefit Policy Manual, that’s one of CMS’ internet-only<br />
manuals. All of <strong>the</strong> internet-only manuals are available on <strong>the</strong> CMS website.<br />
But specifically what you want to look for is Publication 100-02, <strong>the</strong> <strong>Medicare</strong><br />
Benefit Policy Manual. Once you access that particular manual, you can<br />
choose Chapter 15 and <strong>the</strong>n look under Section 80. And that’s where you’ll<br />
find this information.<br />
OK. And my o<strong>the</strong>r questions, you’d like me to get out of queue and request<br />
<strong>the</strong>m again <strong>the</strong>n<br />
No, go ahead, Amy.<br />
OK. My next question was when submitting questions as a contractor, I know<br />
that your options were e-mail or a fax <strong>the</strong> form. Obviously, you got my<br />
question so it must have worked. I just sent it by e-mail, but <strong>the</strong>re was no way<br />
to attach <strong>the</strong> form. That form isn’t allowed to be saved. So how do people<br />
submit that by email I just actually typed in my question.<br />
You weren’t able to save <strong>the</strong> form, is that what you’re saying It was probably<br />
in a…<br />
An allowable form to be saved.<br />
Mary Muchow: …a PDF document. You can copy and paste <strong>the</strong> information into a Word<br />
document and send that<br />
Amy Green:<br />
Mary Muchow:<br />
I tried to do it into <strong>the</strong> e-mail. I think I tried to do it into a Word document also,<br />
and it just didn’t allow because of <strong>the</strong> type of <strong>the</strong> interactive form that it<br />
doesn’t allow it to happen. So I didn’t know if you guys are aware of that.<br />
OK, we are going to have to revisit that and give that some consideration.<br />
Amy, thank you for letting us know. The o<strong>the</strong>r option that you have is to send<br />
an e-mail with <strong>the</strong> information into medicareadmin@wpsic.com.<br />
5
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Mary Muchow:<br />
Operator:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
OK.<br />
http://www.wpsmedicare.com<br />
And if you would put please <strong>ACT</strong> Topic Suggestion in <strong>the</strong> subject. Our staff<br />
and <strong>Medicare</strong> administration will <strong>the</strong>n know who to forward <strong>the</strong> information to.<br />
OK, and that did work because that’s what I did and you did my questions so.<br />
OK, terrific.<br />
OK. My last question, and I don’t know if this is too claim specific, but it has to<br />
do with <strong>the</strong> RAC audits that have been happening with <strong>the</strong> observation care. I<br />
would like to give you a scenario and see what your thoughts are, is that<br />
something that you can answer on this teleconference<br />
I’m sorry; we’re not able to address that on this teleconference, Amy.<br />
OK. OK, that’s what I needed to know. Thank you very much.<br />
You’re welcome.<br />
Your next question comes from <strong>the</strong> line of Natalie Murphy.<br />
Hi, Natalie.<br />
Hi. I wanted to know, I don’t have a denial but I just have a hypo<strong>the</strong>tical<br />
situation and that is when we do a VAD visit, which is <strong>the</strong> daily management<br />
of <strong>the</strong> VAD machine in <strong>the</strong> hospital, and <strong>the</strong> patient has had a previous, say,<br />
heart transplant. Do we a put a 24 modifier on that visit or a 79 saying I’m<br />
related, or just bill it as a plain visit as <strong>the</strong> 93750<br />
I’m not familiar with <strong>the</strong> … did you say VAD visit Does anyone…<br />
Yes.<br />
Can you please repeat that question<br />
Let’s see, OK.<br />
Are you saying that <strong>the</strong> person who did <strong>the</strong> VAD …<br />
Yes. We put <strong>the</strong> VAD machine in, <strong>the</strong> ventricular assist device. OK. When we<br />
did that, maybe we did an aortic valve replacement.<br />
OK.<br />
But we see <strong>the</strong>m everyday.<br />
Right.<br />
And after that, I know <strong>the</strong> valve replacement would be 90-day global. So do<br />
we put a 79 on <strong>the</strong> following daily visits after or…<br />
6
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
A 79 is for return to surgery.<br />
http://www.wpsmedicare.com<br />
I’m sorry, I mean a 24 modifier.<br />
No. What you’re describing is taking care of <strong>the</strong> patient in <strong>the</strong> typical<br />
postoperative care.<br />
So we shouldn’t be…<br />
Billing, no.<br />
Because that’s interrogation of <strong>the</strong> device in person and everyday, we see<br />
<strong>the</strong>m until <strong>the</strong>y get off <strong>the</strong> machine in order to get a heart transplant.<br />
That’s right. I believe that unless CMS gives you a zero global period, I mean,<br />
typically, when someone has a procedure done in <strong>the</strong> hospital, it is all <strong>the</strong><br />
postoperative care in <strong>the</strong> hospital There are few exceptions like, a<br />
cauterization has a zero global period. But see, I can’t remember off <strong>the</strong> top<br />
of my head what <strong>the</strong> VAD CPT code is.<br />
It’s 93750 and <strong>Medicare</strong> has paid. Say we don’t do a procedure and we just<br />
insert <strong>the</strong> VAD machine and we see <strong>the</strong>m daily, <strong>the</strong>re’s no global for that<br />
93750. So in that case, we do bill.<br />
Dr. Boren: 937…<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
…50.<br />
No, but that’s not putting <strong>the</strong> VAD.<br />
No, we’ve already done that and everyday after we charge.<br />
What’s <strong>the</strong> CPT code for putting in a VAD It should be a 3 something.<br />
It is <strong>the</strong> 33979 – or a 33975, 76, 79. It depends on what type, bilateral or, you<br />
know.<br />
33979. OK, that has a xxx global period. I’m trying to find <strong>the</strong> CMS – xxx<br />
global concept does not apply …<br />
Right.<br />
I have never heard of anyone billing.<br />
We do it everyday, yes.<br />
I see.<br />
We keep <strong>the</strong>m on <strong>the</strong> machine.<br />
That is very interesting.<br />
7
Natalie Murphy:<br />
Dr. Boren:<br />
Beth:<br />
Natalie Murphy:<br />
Beth:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Dr. Boren:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
And that my question was when it’s done with, say, ano<strong>the</strong>r procedure, I<br />
know <strong>the</strong> o<strong>the</strong>r http://www.wpsmedicare.com<br />
procedure is 90 days, but we really able to bill that VAD<br />
visit even though it’s bumping up against <strong>the</strong> o<strong>the</strong>r 90-day global Do you<br />
see what I mean<br />
I know what you mean but…<br />
Dr. Boren, this is Beth. I have a CPT book. And under code 93750, it does<br />
say do not report 93750 in conjunction with 33975, 33976, 33979…<br />
That’s insertion.<br />
OK. So is that not what you’re saying<br />
No. We have already put it in. And <strong>the</strong>n every day after, we have to visit<br />
<strong>the</strong>m, interrogate <strong>the</strong> device in person, analyze <strong>the</strong> machine to see what it’s<br />
doing and <strong>the</strong>n we bill for that.<br />
I will talk to <strong>the</strong> head of CCI and find out his thoughts on that. Because I have<br />
a problem because this to me should be part of <strong>the</strong> service. But I will see if it<br />
he looks at it <strong>the</strong> same way.<br />
And to me, this right here, this code is a procedure and not a hospital visit.<br />
That’s why I wondered about <strong>the</strong> modifier 79 saying it’s unrelated to <strong>the</strong> aortic<br />
valve procedure that was done maybe at <strong>the</strong> same time. Since it’s not an E/M<br />
code, you can’t put <strong>the</strong> 24 on this. Do you see what I mean<br />
I would suggest that this should be something that we’d want to take a look at<br />
and follow up on.<br />
OK.<br />
And have her pass that information, please.<br />
Can you provide your contact information for us, please Perhaps, a first<br />
name and a telephone number.<br />
Yes. And what – how do I do that I mean, just give it to you now<br />
Yes. If you would unless you’re in objection to doing so, you could e-mail it...<br />
Oh, no.<br />
…to us later.<br />
No.<br />
OK.<br />
My name is Natalie.<br />
8
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Mary Muchow:<br />
Natalie Murphy:<br />
Operator:<br />
Beth Fact:<br />
Mary Muchow:<br />
Beth Fact:<br />
Mary Muchow:<br />
OK, Natalie.<br />
http://www.wpsmedicare.com<br />
OK and my – do you want my phone number<br />
Yes, please.<br />
I mean 816, sorry, 931-33<strong>12</strong>. And I’m with Kansas City Heart & Lung<br />
Surgeons.<br />
Thank you, Natalie.<br />
Thank you.<br />
Someone will follow up with you in just a couple of days.<br />
OK.<br />
I think if you have an ICN example for us where we could actually look at <strong>the</strong><br />
claim, we could look at <strong>the</strong> codes, we could check National Correct Coding<br />
Initiative edits a well as <strong>the</strong> information on <strong>the</strong> <strong>Medicare</strong> Physician Fee<br />
Schedule database.<br />
OK.<br />
All of those tools will be of great assistance to us and I’m sure that we’ll be<br />
able to answer your question.<br />
OK, I’ll have several examples for you.<br />
All right, thanks so much.<br />
All right.<br />
Your next question comes from <strong>the</strong> line of Beth Fact.<br />
Yes, I apologize; I was looking at something else. I’m calling for Regional<br />
Medical Laboratory and Pathology Laboratory Associates. I’m asking a<br />
question for ano<strong>the</strong>r member, it has to do with <strong>the</strong> molecular pricing and she<br />
has asked, “It appears <strong>the</strong> new molecular codes will be priced by each MAC<br />
until CMS has enough information and to include <strong>the</strong>m on <strong>the</strong> fee schedule.<br />
Will <strong>WPS</strong> pricing compile <strong>the</strong>se and a file available for download Or will we<br />
have to search each one individually on <strong>the</strong> <strong>WPS</strong> website”<br />
That is something that we’re going to have to follow up on, Beth.<br />
OK.<br />
I don’t have anyone here to represent fees, but what you’re telling me is that<br />
<strong>the</strong>se are going to be carrier priced services.<br />
9
Beth Fact:<br />
Mary Muchow:<br />
Beth Fact:<br />
Dr. Boren:<br />
Beth Fact:<br />
Dr. Boren:<br />
Beth Fact:<br />
Dr. Boren:<br />
Beth Fact:<br />
Dr. Boren:<br />
Beth Fact:<br />
Dr. Boren:<br />
Beth Fact:<br />
Mary Muchow:<br />
Beth Fact:<br />
Mary Muchow:<br />
Correct. The procedure codes are in <strong>the</strong> 20<strong>12</strong> procedure manual but <strong>the</strong>y’re<br />
not in place http://www.wpsmedicare.com<br />
as of yet. It’s for <strong>the</strong> stacking code for <strong>the</strong> molecular testing.<br />
There was 101 of <strong>the</strong>m and now, <strong>the</strong>y say effective, January of 2013 that<br />
<strong>the</strong>se will go into effect and we’re trying to get our pricing within our system<br />
and get it correct. But we don’t know where to – <strong>the</strong>y’re on <strong>the</strong> fee schedule<br />
right now but with no pricing. So we’re trying to figure out how and when that<br />
will be available for us to be able to put in to our system.<br />
And Beth, do you have a range of codes that you can give me<br />
Let’s see.<br />
One thing – Dr. Boren here. We do not price any CPT code until we have<br />
received a claim.<br />
Once you received <strong>the</strong> claim that is showing that it has <strong>the</strong> new molecular<br />
code, that’s when <strong>the</strong> allowable would be considered<br />
Correct. We have never priced CPT codes or any procedure until those are<br />
claimed. What happened in <strong>the</strong> past is a number of manufacturers who have<br />
come up with new ideas, new products, <strong>the</strong>y want to know how much this<br />
thing will pay so that <strong>the</strong>y could decide about marketing efforts.<br />
OK. Well, you currently have a fee schedule that we do our pricing off of. So<br />
how was this any different<br />
Basically, <strong>the</strong> pathology fees are typically – most of <strong>the</strong>m are set by CMS.<br />
OK.<br />
Now…<br />
CMS is saying <strong>the</strong> MAC will be you – I understand now what you’re saying.<br />
You will not do anything or any pricing until it comes across and that will be<br />
determined at that time.<br />
Correct.<br />
OK. And I do not have <strong>the</strong> list of <strong>the</strong> new molecular codes in front of me. I can<br />
get that for you if you need. But I think he just answered my question as far<br />
as…<br />
Right. And just to clarify, what I was saying that once established, what I<br />
could do is check to see if <strong>the</strong>y would be published. But that would be only<br />
after that claim is submitted and <strong>the</strong>re is pricing eventually established. So…<br />
Yes. It sounds more like we’re going to have to submit <strong>the</strong> claim. If for any<br />
reason denied or what, <strong>the</strong>n we would have to provide <strong>the</strong> documentation to<br />
support it at that time.<br />
That’s correct.<br />
10
Beth Fact:<br />
Mary Muchow:<br />
Beth Fact:<br />
Operator:<br />
I think you answered my question, OK.<br />
All right. Thanks, Beth.<br />
http://www.wpsmedicare.com<br />
Thank you.<br />
Your next question comes from <strong>the</strong> line of Jennifer Vanwinkle.<br />
Jennifer Vanwinkle:<br />
Hello. <br />
Mary Muchow:<br />
Hi. <br />
Jennifer Vanwinkle: Actually, my first thing is that I had submitted a topic that you guys did not <br />
discuss.<br />
Mary Muchow:<br />
OK.<br />
Jennifer Vanwinkle:<br />
That’s <strong>the</strong> routine foot care.<br />
Mary Muchow:<br />
How can we help you<br />
Jennifer Vanwinkle: We’re just trying to figure out, I’m getting many denials on patients who<br />
are elderly that are not diabetic.<br />
Mary Muchow:<br />
Dr. Boren:<br />
Male:<br />
Mary Muchow:<br />
Male:<br />
Dr. Boren:<br />
Mary Muchow:<br />
OK.<br />
Elderly alone doesn’t mean that you’re entitled to foot care. This is a benefit<br />
given by <strong>Medicare</strong> by law but <strong>the</strong>re are restrictions.<br />
And physical findings that are documented in <strong>the</strong> chart, would it be a Class A<br />
finding of amputation of a portion of <strong>the</strong>ir foot or, two, Class B findings or<br />
class being Class C finding. If <strong>the</strong>y have those physical findings, <strong>the</strong>n <strong>the</strong>y<br />
qualify. Hello.<br />
Yes.<br />
So why are <strong>the</strong>y being denied <strong>the</strong>n If <strong>the</strong>y’ve got <strong>the</strong> physical findings to<br />
qualify <strong>the</strong>m, why are <strong>the</strong> claims being denied<br />
Perhaps, <strong>the</strong>y’re not being billed correctly. I mean, you have to look at your<br />
denial message.<br />
Right and that’s something that customer service can help you with. If you<br />
call <strong>the</strong>m and you give <strong>the</strong>m an ICN, <strong>the</strong>y can look at <strong>the</strong> claim and see how<br />
it processed, see what was reported on <strong>the</strong> claim, and <strong>the</strong>n provide you with<br />
assistance. This is claim-specific information, and I’m sorry we’re not able to<br />
provide during this call.<br />
Jennifer Vanwinkle: Well, more of a general question not claim-specific because sometimes<br />
we submit a claim and <strong>the</strong>y get paid on certain patients who are not diabetic<br />
<strong>11</strong>
and <strong>the</strong>n <strong>the</strong> o<strong>the</strong>r ones do not. And so I’m trying to understand, we submit<br />
<strong>the</strong>m all <strong>the</strong> http://www.wpsmedicare.com<br />
same and why one gets paid and one doesn’t.<br />
Dr. Boren:<br />
The question is, are you really submitting <strong>the</strong>m all <strong>the</strong> same Because a<br />
number of times, people think <strong>the</strong>y are <strong>the</strong> same, my field is emergency<br />
medicine. My group complained to me about <strong>Medicare</strong> denials and <strong>the</strong>y<br />
showed me a bunch of denials that <strong>the</strong>y had gotten. I asked <strong>the</strong>m why <strong>the</strong>y<br />
have a box open. I forgot which one it was that needed to be filled out and<br />
<strong>the</strong>y had left that box open on a number of claims. I just asked <strong>the</strong>m why<br />
<strong>the</strong>re were filling out paper claims instead of electronic. That would kind of<br />
surprise me.<br />
Jennifer Vanwinkle: Well, whenever – I mean, by <strong>the</strong> same claim is that – if it falls (inaudible)<br />
<strong>the</strong>n we use that same code. It can be a diagnosis of <strong>the</strong> <strong>11</strong>0.1.<br />
Dr. Boren:<br />
Brett:<br />
You need to let <strong>the</strong> customer service look up <strong>the</strong> denial reason.<br />
Hey, Dr. Boren, this is Brett, Manager of Medical Review. I believe that’s<br />
mycotic nails and <strong>the</strong>re are different exceptions for mycotic nails versus a<br />
systemic condition, which requires a professional to trim <strong>the</strong> nail. So I would<br />
advice going back and look because <strong>the</strong>re are different requirements for both.<br />
So if you are billing debridement for mycotic nails, <strong>the</strong>re’s a certain way <strong>the</strong><br />
claim and needs to be submitted. If you are billing routine foot care exception<br />
due to a systemic condition with class findings, <strong>the</strong>re are o<strong>the</strong>r things that<br />
need to be on that billing and again, without claim-specific information, we<br />
can’t tell. But those are two separate exceptions, mycotic nails that need<br />
certain things and <strong>the</strong>n systemic condition with certain findings which require<br />
professionals to do that routine foot care safely.<br />
Jennifer Vanwinkle:<br />
Thank you so much.<br />
Mary Muchow:<br />
Operator:<br />
Mary Muchow:<br />
Kara Lithcum:<br />
Beth:<br />
You’re welcome.<br />
Your next question comes from <strong>the</strong> line of Kara Lithcum.<br />
Hi, Kara.<br />
Hi. I have a question regarding LCDs. My question is, we have a service that<br />
always gets denied for medical necessity because <strong>the</strong> diagnosis we’re using<br />
is not on <strong>the</strong> on <strong>the</strong> LCD. We eventually take this to a judge and our appeals<br />
get overturned. So I would like to know how we can transfer that information<br />
to get <strong>the</strong> LCD at least get it considered for a change.<br />
Hi, this is Beth from <strong>the</strong> Policy Department. We do have an e-mail box that<br />
will take you – <strong>the</strong> emails are addressed by <strong>the</strong> Policy department. It’s<br />
policycomments@wpsic.com. If you’d let us know your request in an LCD<br />
reconsideration and you’d let us know what policy it is and we have a page<br />
on our website that will also explain <strong>the</strong> type of literature that we like to see<br />
included with your LCD reconsideration request.<br />
<strong>12</strong>
But if you ever see a policy, we really encourage you that you fill this missing<br />
coverage and http://www.wpsmedicare.com<br />
you have literature to support it, we really encourage you to<br />
submit that via <strong>the</strong> policy comment box. It will save a little work on your end<br />
by having to take it through appeals.<br />
Kara Lithcum:<br />
Beth:<br />
Kara Lithcum:<br />
Beth:<br />
Kara Lithcum:<br />
Beth:<br />
Mary Muchow:<br />
Kara Lithcum:<br />
Mary Muchow:<br />
Operator:<br />
OK. And where is that at on your website<br />
Go to <strong>the</strong> Policy page and <strong>the</strong>n on <strong>the</strong> left-hand side, you can click on and go<br />
to our Draft Policies. And I know <strong>the</strong>re’s an actual link that will bring up an e-<br />
mail that says Policy Comments on it.<br />
OK, I found it. OK.<br />
And <strong>the</strong>n it…<br />
And <strong>the</strong>n it lists what we need to include.<br />
Right, exactly.<br />
I believe <strong>the</strong>re’s an actual article out <strong>the</strong>re for policy reconsideration request,<br />
and it includes a very good listing of <strong>the</strong> information or <strong>the</strong> type of information<br />
that you have to include when sending that information in.<br />
OK, yes. Because we do have peer reviewed evidence and I can’t imagine<br />
why it wouldn’t change, so. OK, we will do that <strong>the</strong>n. Thank you.<br />
Thank you.<br />
Your next question comes from <strong>the</strong> line Kristine Aprenger.<br />
Kristine Aprenger: Hi, my question is for Provider Enrollment. I want to see what is <strong>the</strong> expected<br />
timeframe for a provider to become approved with notice of tremendous<br />
slowdown and we’ve been told it’s due to o<strong>the</strong>r revalidation applications that<br />
<strong>the</strong>y’re working.<br />
Chere:<br />
Hi, this is Chere with Provider Enrollment. That’s probably pretty true. CMS<br />
gives us <strong>the</strong> timeframes of 60 days to process that in a timely manner. If<br />
you’re having issues that it’s going over <strong>12</strong>0 days <strong>the</strong>n we can certainly take<br />
a look at <strong>the</strong>m. But <strong>the</strong> revalidation has really slowed us down.<br />
Kristine Aprenger: OK, because I know that we have some that have gone past <strong>the</strong> 60-day<br />
timeframe now. And <strong>the</strong> odd thing is that we’ve had one provider that we’ve<br />
submitted after <strong>the</strong> rest of <strong>the</strong>m and he, like, went through within a couple of<br />
weeks.<br />
Chere:<br />
So are <strong>the</strong>se new provides or are <strong>the</strong>y revals that you’re sending in<br />
Kristine Aprenger: These are new provider applications.<br />
Chere:<br />
If you have concerns, go ahead and call <strong>the</strong> hotline, and we can try and pull it<br />
out or something.<br />
13
Kristine Aprenger: OK. And <strong>the</strong>n <strong>the</strong> second question is, has <strong>the</strong>re been any discussions about<br />
recognizing hospitalist http://www.wpsmedicare.com<br />
as a specialty<br />
Mary Muchow:<br />
Dr. Boren:<br />
I’m not aware of anything.<br />
Dr. Boren here. The decision to create a separate physician specialty or o<strong>the</strong>r<br />
specialty right rest solely with CMS.<br />
Kristine Aprenger: OK.<br />
Dr. Boren:<br />
And so <strong>the</strong>re would be solely a decision by CMS.<br />
Kristine Aprenger: All right, thank you.<br />
Dr. Boren:<br />
Operator:<br />
Lauren Craig:<br />
Carol:<br />
Lauren Craig:<br />
Carol:<br />
Lauren Craig:<br />
Carol:<br />
Operator:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Cathy Smith:<br />
You’re welcome.<br />
Your next question comes from <strong>the</strong> line of Lauren Craig.<br />
Hi. My question is actually policy related to <strong>the</strong> policy for application of skin<br />
substitute. We work with <strong>the</strong> skin substitute indicated for diabetic with ulcer<br />
and we’re just wondering if <strong>the</strong> application for <strong>the</strong> ankle would be covered<br />
given that CPT considers <strong>the</strong> ankle to be a part of <strong>the</strong> leg.<br />
This is Carol. Dr. Boren, unless you have anything to add, I’m going to ask<br />
that that question be submitted in <strong>the</strong> policy comment box so that it can be<br />
researched. Would you mind…<br />
I’ve also researched it just a little bit on <strong>the</strong> website and it does appear that<br />
<strong>the</strong> CPT 15271 is <strong>the</strong> payable code for podiatrist, but I do have a number of<br />
podiatrists that are a little bit concerned, and we just want a little bit of<br />
clarification.<br />
I think if you put it in writing and send it in through <strong>the</strong> email so we can get it<br />
researched. OK<br />
That would be great. Thank you.<br />
Thanks.<br />
Your next question comes from <strong>the</strong> line of Cathy Smith.<br />
Hello.<br />
Hi, Cathy, go ahead.<br />
I’ve got a question regarding take-backs. I believed you mentioned that in<br />
your opening. As far as take-back requests go, can you tell me how that<br />
process is and what information is on <strong>the</strong> remit for us to know who that take<br />
back is being taken back from<br />
14
Jenny:<br />
Cathy Smith:<br />
Jenny:<br />
Cathy Smith:<br />
Jenny:<br />
Cathy Smith:<br />
Jenny:<br />
Cathy Smith:<br />
Jenny:<br />
Cathy Smith:<br />
Jenny:<br />
Cathy Smith:<br />
Jenny:<br />
Cathy Smith:<br />
Dr. Boren:<br />
Oh, this is Jenny with Payment Recovery Area. Are you referring to at <strong>the</strong><br />
bottom of <strong>the</strong> remittance notice, remark code WO<br />
http://www.wpsmedicare.com<br />
Probably. I do not know that it’s <strong>the</strong>re. I can’t remember exactly where it is or<br />
exactly what <strong>the</strong> information is. I have seen it. I don’t have one in front of me<br />
now, but we are having a lot of take-backs right now because we had to go<br />
back and correct a lot of billing errors for procedures. So we’re getting takebacks<br />
from <strong>the</strong> remits. But we just need to know <strong>the</strong> best way to get <strong>the</strong><br />
information to know who that money is being taken back from.<br />
All right. So to match up your withholdings or your offsets on your remit<br />
notice, <strong>the</strong>re’s a couple of different things you can do. Do you keep a copy of<br />
your demand letters that you received<br />
Yes, ma’am.<br />
On <strong>the</strong> demand letters, all of <strong>the</strong>m have an accounts receivable number or an<br />
invoice number. If you keep that letter and <strong>the</strong>n match it up to your remittance<br />
notice, at <strong>the</strong> bottom <strong>the</strong>re’s <strong>the</strong> WO. That will give you <strong>the</strong> invoice number<br />
that matches your letter and <strong>the</strong>n it will give you a patient account number if<br />
you bill with <strong>the</strong> patient account number.<br />
OK.<br />
If you do not bill with <strong>the</strong> patient account number <strong>the</strong>n <strong>the</strong> <strong>Medicare</strong> number<br />
will be provided.<br />
OK.<br />
Ano<strong>the</strong>r option you can do is if you have that invoice number, you could take<br />
that into C-SNAP and you can put in <strong>the</strong> invoice number and it’ll give you <strong>the</strong><br />
patient’s name and date of service.<br />
OK, good. What is <strong>the</strong> difference in getting <strong>the</strong> request for a refund Like, if<br />
we get a request from you on a refund and it’s not on our remit versus it only<br />
being on <strong>the</strong> remit, or is that – does that even happen<br />
The request for refund, <strong>the</strong> letter, you’ll first receive a demand letter. Then<br />
after 41 days or whenever that demand is offset, <strong>the</strong>n <strong>the</strong> WO will appear on<br />
your remittance notice.<br />
OK.<br />
It’s not at <strong>the</strong> same time. You’ll have to wait if <strong>the</strong> claim is offset.<br />
Right. OK. All right, thank you.<br />
Mary, I don’t want to interrupt, but to answer <strong>the</strong> question that Natalie asked<br />
about <strong>the</strong> VAD. It is not a CCI issue unless it’s <strong>the</strong> date it was inserted.<br />
Because on <strong>the</strong> date it’s inserted, it hits a modifier. But that would not be an<br />
15
issue after <strong>the</strong> day of insertion. The CCI only talks about <strong>the</strong> concurrent<br />
dates. http://www.wpsmedicare.com<br />
Mary Muchow:<br />
Operator:<br />
Lisa Armstrong:<br />
Mary Muchow:<br />
Male:<br />
Dr. Boren:<br />
Male:<br />
Dr. Boren:<br />
Male:<br />
Dr. Boren:<br />
Mary Muchow:<br />
Operator:<br />
Jim Williams:<br />
May Muchow:<br />
Jim Williams:<br />
Same provider, same date of service, same encounter.<br />
Your next question comes from <strong>the</strong> line of Lisa Armstrong.<br />
Hello.<br />
Hi.<br />
We have a question regards to ambulance transports and <strong>the</strong> day of hospital<br />
admit. If <strong>the</strong> patient arrived at hospital A to <strong>the</strong> emergency room, is admitted<br />
by <strong>the</strong> emergency room division. He writes <strong>the</strong> order according to <strong>the</strong><br />
<strong>Medicare</strong> manual and <strong>the</strong> patient is <strong>the</strong>n transferred by ambulance to ano<strong>the</strong>r<br />
hospital that shares <strong>the</strong> same provider number after those orders are written<br />
but it’s <strong>the</strong> same date. Is that a Part A billable or is that a Part B billable<br />
We’d have to look that up. But I don’t think it’s payable because when it’s<br />
considered to be like you took <strong>the</strong> person from one floor of <strong>the</strong> hospital to<br />
ano<strong>the</strong>r floor.<br />
So it would <strong>the</strong> responsibility of <strong>the</strong> facility not <strong>Medicare</strong>.<br />
Right. If it’s <strong>the</strong> same provider number, that is no different than when you take<br />
<strong>the</strong>m from <strong>the</strong> emergency department to CAT scan or something as far as<br />
we’re concerned. I don’t think <strong>the</strong>re’s any o<strong>the</strong>r way of looking at it if it’s –<br />
sometimes, we have situations where you have big campuses and you could<br />
have a different provider number on different parts. But that’s still an inter –<br />
it’s <strong>the</strong> hospital to self transfer, not to ano<strong>the</strong>r facility<br />
Okay, next. Even it – because it’s – after <strong>the</strong> orders for admit are written, it<br />
becomes <strong>the</strong> facility’s responsibility. Correct<br />
It’s in <strong>the</strong> – if <strong>the</strong> person is in <strong>the</strong> emergency department and he is going to<br />
ano<strong>the</strong>r place in <strong>the</strong> hospital, it’s <strong>the</strong> same provider number.<br />
OK.<br />
Your next question comes from <strong>the</strong> line of Jim Williams.<br />
Hi.<br />
Hi.<br />
I have a question and it might have been partially answered by someone from<br />
ano<strong>the</strong>r field earlier, but we are an optometrist office. I noticed one of <strong>the</strong> –<br />
we haven’t gotten any rejections yet from <strong>Medicare</strong> but specifically on<br />
procedure code 92250 which is a fundus photography. It looks like <strong>the</strong> LCD<br />
got changed and it got put under a low vision coverage, I guess, which I<br />
believe is <strong>the</strong> 32007. Have you had any feedback on how that procedure<br />
16
code got moved under low vision services or not at this point Does any of<br />
<strong>the</strong> make sense http://www.wpsmedicare.com<br />
to you<br />
Bonnie:<br />
Jim Williams:<br />
Dr. Boren:<br />
Jim Williams:<br />
Dr. Boren:<br />
Jim Williams:<br />
Dr. Boren:<br />
This is Bonnie. The 99250, <strong>the</strong> fundus photography, is payable for more than<br />
what’s in <strong>the</strong> low vision, of course and that’s why you’re not getting any<br />
denials.<br />
Yes. And we haven’t gotten any from you all and we don’t have any problems<br />
with <strong>Medicare</strong> or with <strong>WPS</strong> specifically.” We’ve had a couple of – oh, come<br />
on, brain think – Humana and <strong>Medicare</strong> replacement policies that have<br />
refused to pay that and said, “OK.” You know <strong>the</strong>y’re saying that <strong>the</strong> fundus<br />
photography falls under low vision services and to check back with our<br />
<strong>Medicare</strong> carrier for that LCD. Like I said, we’ve been getting paid on it and I<br />
just, you know, while we’re doing this, I know that changed on 8/20. I’m<br />
looking at my newest remittance advice and I see that we’ve gotten paid for it<br />
on, you know, date of service 8/24. So I don’t know if something is out of<br />
whack with <strong>the</strong> Humanas of <strong>the</strong> world and <strong>the</strong> <strong>Medicare</strong> replacements. How<br />
would you go about, you know, changing that or…<br />
But if <strong>the</strong> problem is not with us.<br />
Right.<br />
That I’ve enough trouble doing my own job without trying to do <strong>the</strong> job for<br />
Humana company, so…<br />
Yes and that’s just it. You know, <strong>the</strong>y’d say, “OK, go back to your <strong>Medicare</strong><br />
provider or your <strong>Medicare</strong> carrier" and we don’t have any problem<br />
whatsoever with our <strong>Medicare</strong>. They’re still being paid through because <strong>the</strong><br />
diabetic code is <strong>the</strong> macular degeneration code, it’s a glaucoma code, but<br />
<strong>the</strong>y’re disallowing on all those o<strong>the</strong>r ones and I know that’s not <strong>WPS</strong>’<br />
problem, but <strong>the</strong>y keep pointing it back at our carrier. So I guess we’ll just<br />
kind of go <strong>the</strong>ir chain of command and – but I didn’t know if you guys took<br />
that code out of general usage and just lumped it under that, you know …<br />
It’s very difficult to have any specific CPT code in two separate policies.<br />
Because what happens is you cannot send out a denial <strong>the</strong>n based on <strong>the</strong><br />
policy number because <strong>the</strong> computer sees two different policies with that<br />
CPT code. So I’m not familiar with any contractor that has a CPT code that is<br />
in two separate policies.<br />
I suppose it could be – I just can’t think of any because it becomes a real<br />
systems issue when that happens.<br />
Jim Williams:<br />
Yes and I guess I was just worried that that’s what this would become.<br />
Because of this fundus photography got pulled under <strong>the</strong> 32007 ad I guess<br />
I’m just trying to read into it and say, “OK, if that is under that LCD now and<br />
we go down and see <strong>the</strong> ICD 9 codes that support <strong>the</strong> necessity, <strong>the</strong>y’re all a<br />
low vision code.” If we look at that particular LCD.<br />
17
Chere:<br />
Jim Williams:<br />
Mary Muchow:<br />
Jim Williams:<br />
Mary Muchow:<br />
Jim Williams:<br />
Mary Muchow:<br />
Jim Williams:<br />
Mary Muchow:<br />
Jim Williams:<br />
Mary Muchow:<br />
Jim Williams:<br />
Chere:<br />
Operator:<br />
Amy Green:<br />
Mary Muchow:<br />
Amy Green:<br />
Well, I can tell you that Dr. Boren and I have discussed this and we are going<br />
to put into <strong>the</strong> http://www.wpsmedicare.com<br />
low vision policy just a statement or a phrase stating that <strong>WPS</strong><br />
realizes that fundus photography is used of broader ranges than included in<br />
this policy. And that might be something that you can give to Humana or<br />
whoever. But you would hope that <strong>the</strong>y would note that <strong>the</strong>mselves.<br />
Yes, that’s what I’m thinking and <strong>the</strong> way <strong>the</strong> LCD is written, it should exclude<br />
that procedure. But <strong>the</strong> fact that we’re still getting paid now that <strong>the</strong> new<br />
month had started, but <strong>the</strong> effective date was 8/20 of 20<strong>12</strong>, and we’re still<br />
getting paid on <strong>the</strong> side. I was just kind of preparing for <strong>the</strong> what if things<br />
change.<br />
Yes. This is Mary…<br />
You know, start of <strong>the</strong> new month so we’re starting to get denials, we’re just<br />
going to keep an eye on it.<br />
Right. Your next step would <strong>the</strong>n to go back to <strong>the</strong> plan.<br />
Yes. I think that’s more of a Humana issue not…<br />
Correct.<br />
…and well I guess, we’ll just wait for <strong>the</strong> revision because that’s about <strong>the</strong><br />
only place that I can find that particular procedure code, <strong>the</strong> 92250s, within<br />
<strong>the</strong> low vision LCD, so.<br />
OK.<br />
So we’ll, I guess, we’ll just kind of keep experimenting with it and if we have<br />
problems with it in <strong>the</strong> future, get back with you on that.<br />
All right.<br />
OK. Thank you very much.<br />
You’re welcome.<br />
Question comes from <strong>the</strong> line of Amy Green.<br />
Hi.<br />
Hi, Amy.<br />
I was told before that maybe <strong>the</strong> observation care was more claim specific. I<br />
just want to give you a scenario. It’s not directly related to one claim. What<br />
my question is, <strong>the</strong> family medicine physician admits a patient to observation<br />
at 1:33 am. Twelve hours later on <strong>the</strong> same day, an internal medicine doctor<br />
discharged patient. It is <strong>the</strong> same physician’s group but different specialties.<br />
Is it correct to bill 99219, which is an initial observation care for a family<br />
medicine physician, and 99217, which is an observation care discharge for<br />
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<strong>the</strong> internist, because <strong>the</strong>y’re two different – with a different specialty and a<br />
different person, http://www.wpsmedicare.com<br />
but same group.<br />
Brett:<br />
Amy Green:<br />
Brett:<br />
Amy Green:<br />
Brett:<br />
Amy Green:<br />
Brett:<br />
Amy Green:<br />
Brett:<br />
Mary Muchow:<br />
This is Brett from Medical Review. We’re going to have to research that one a<br />
little bit more. And specifically, is it under <strong>12</strong> or over <strong>12</strong>, did you say<br />
Over <strong>12</strong> hours.<br />
Over <strong>12</strong> hours<br />
Yes. I’ve taken this to, like, a tier two specialist and I still – <strong>the</strong>re is nothing in<br />
<strong>the</strong> manual and so forth. We have all <strong>the</strong> guidelines from 30.6.8 from <strong>the</strong><br />
manual that differentiates from when it’s a different specialty.<br />
OK and could I ask what PRRS specialist response you have received from<br />
<strong>the</strong>m<br />
There was nothing in <strong>the</strong>re because <strong>the</strong>re was nothing that talks about<br />
different specialties.<br />
OK. We’ll research that, I’m sure you’re talking about in a different section not<br />
so much specific to that code about providers of <strong>the</strong> same specialty, same<br />
group are treated as one physician of <strong>the</strong> same day. But as far as – I would<br />
need some time to do some research in regards to <strong>the</strong> observation care<br />
codes and especially with <strong>the</strong> <strong>12</strong> over/under because I assume – obviously,<br />
one is that initial observation care and <strong>the</strong>n <strong>the</strong> second one would be billing<br />
as a discharge. So I…<br />
Right.<br />
…need to research that a little bit more.<br />
Amy, can we get a telephone number from you And someone will follow up<br />
with you, please.<br />
Amy Green: Sure. It’s (563) 584-4170.<br />
Mary Muchow:<br />
Could you repeat <strong>the</strong> area code, please<br />
Amy Green: 563.<br />
Mary Muchow:<br />
Amy Green:<br />
Operator:<br />
Laurie Weber:<br />
OK, thank you.<br />
Thank you.<br />
Your next question comes from <strong>the</strong> line of Laurie Weber.<br />
Yes. I have a question about <strong>the</strong> multiple E/M codes in on a single day also.<br />
What qualifies a different group Is that you’re billing under a different NPI or<br />
a different tax ID number Can you clarify that for us<br />
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Brett:<br />
Chere:<br />
Laurie Weber:<br />
Chere:<br />
Laurie Weber:<br />
Chere:<br />
Laurie Weber:<br />
Chere:<br />
Laurie Weber:<br />
Brett:<br />
Chere:<br />
Laurie Weber:<br />
Operator:<br />
Vicki Graham:<br />
Brett:<br />
Vicki Graham:<br />
Chere:<br />
Brett:<br />
Mary Muchow:<br />
Actually I’m going to throw that over to Chere. <br />
http://www.wpsmedicare.com<br />
Well, but are <strong>the</strong>y talking about claims, like, if a patient is seen by two doctors <br />
within <strong>the</strong> same group, it looks at <strong>the</strong> tax ID.<br />
It looks at <strong>the</strong> tax ID not <strong>the</strong>…<br />
Yes.<br />
…billing group NPI.<br />
No. No. Right.<br />
Just <strong>the</strong> tax ID.<br />
So if two doctors under <strong>the</strong> same tax ID saw that patient, that’s considered<br />
concurrent care.<br />
OK. That answers my question.<br />
Provided <strong>the</strong>y’re <strong>the</strong> same specialty.<br />
Right, right.<br />
Thank you.<br />
Your next question comes from <strong>the</strong> line of Vicki Graham.<br />
Hi. I have an ambulance question about return transfers. We live in a very<br />
super rural area, and say, we need to transfer a patient for a broken hip. We<br />
transferred him to see an orthopedic surgeon. They have <strong>the</strong>ir surgery and<br />
<strong>the</strong>n <strong>the</strong>y want us to transfer him back to our facility. Is that covered by<br />
<strong>Medicare</strong><br />
This is Brett. Let me just kind of ask you a few questions, we might have to<br />
research this one. Now, when you referred to your facility, what do you mean<br />
by that Are <strong>the</strong>y coming from a nursing home Are <strong>the</strong>y coming from <strong>the</strong>ir<br />
home to <strong>the</strong> surgery What’s <strong>the</strong> origin<br />
From our hospital. We have a small hospital, and we transport to a larger<br />
hospital that has a specialist or surgeon. So will <strong>the</strong>y pay for from <strong>the</strong> larger<br />
facility to a lower level of care<br />
No.<br />
Generally, we only cover to <strong>the</strong> hospital where <strong>the</strong>re’s a surgeon who was<br />
able to provide those services, <strong>the</strong>n <strong>the</strong>y should be provided <strong>the</strong>re. But if <strong>the</strong><br />
patient’s preference to go to a different site, <strong>the</strong>n it would be <strong>the</strong> patient’s<br />
responsibility for that transport.<br />
Nearest appropriate facility.<br />
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Vicki Graham:<br />
Operator:<br />
Richard Farley:<br />
Brett:<br />
Richard Farley:<br />
Brett:<br />
Richard Farley:<br />
Brett:<br />
Richard Farley:<br />
Brett:<br />
Mary Muchow:<br />
OK, thank you.<br />
http://www.wpsmedicare.com<br />
Your next question comes from <strong>the</strong> line of Richard Barley. Excuse me,<br />
Farley.<br />
Hi, I have two quick questions. There’s a code for preparation of antigens for<br />
allergen immuno<strong>the</strong>rapy, 95165, and we’ve had an allergist for about three<br />
years and we haven’t had any problems with this code until this year. There<br />
seems to be a medically unbelievable edit that set it like 30 and we never<br />
prepare antigens less than 36 doses. So I’m not sure if this is a mistake or<br />
how do we address that, or this seems like <strong>the</strong> medically unbelievable edit is<br />
set medically unbelievably low.<br />
This is Brett, Medical Review. Are you doing <strong>the</strong> drops<br />
He prepared a little vial and <strong>the</strong>n take (inaudible) out of that for 36 doses.<br />
And <strong>the</strong>n…<br />
It is typical.<br />
Does <strong>the</strong> patient take those sublingually<br />
No, this is for injection.<br />
We’re probably going to have to research that one.<br />
There is information published on <strong>the</strong> CMS National Correct Coding Initiative<br />
webpage that includes information about medically unlikely edits. It does<br />
provide for you <strong>the</strong>re on that CMS web page a contact. If you disagree with<br />
an MUE that is established by and published by <strong>the</strong> CMS contractor, publish<br />
<strong>the</strong>m on <strong>the</strong> CMS web page. Remember that not all MUEs are indeed<br />
published, but <strong>the</strong>re is a listing of <strong>the</strong> contractor that you can go to, to present<br />
your case if you will.<br />
If you need that information, I don’t have a computer here in <strong>the</strong> room. I can<br />
take your number and I can give you a call, Richard.<br />
Richard Farley: OK. Yes, it’s (563) 589-4058.<br />
Mary Muchow:<br />
Richard Farley:<br />
OK.<br />
Then my o<strong>the</strong>r question is about this – and I’m not sure where this is, and <strong>the</strong><br />
medical director sort of forwarded to me but I’m not sure if this has been fixed<br />
or not. But <strong>the</strong>re was this talk about how you are in PECOS and if you don’t<br />
list <strong>the</strong> referring provider just right, your claims are going to be denied and I<br />
just want to give an example of why this is so difficult for us. It seems pretty<br />
simple on <strong>the</strong> surface.<br />
Then if you can give <strong>the</strong> right place to go to get <strong>the</strong> proper list. But we were<br />
looking for a referring physician from <strong>the</strong> University of Iowa. We’re in Iowa<br />
21
and <strong>the</strong> doctor was listed. We know this doctor by her published name at <strong>the</strong><br />
university but http://www.wpsmedicare.com<br />
she’s in <strong>the</strong> PECOS or <strong>the</strong> NPPES with her maiden name and<br />
her last name <strong>the</strong>re. When we searched for her last name, it didn’t come up<br />
because it was in <strong>the</strong>re as her maiden name. And sometimes if you have MD,<br />
that doesn’t work. And sometimes it does work and maybe you know about<br />
<strong>the</strong>se problems or don’t know about <strong>the</strong>se problems, but those are <strong>the</strong> types<br />
of reasons why we can’t find <strong>the</strong> referring doctor even in <strong>the</strong> NPPES because<br />
<strong>the</strong> names and <strong>the</strong> search engines don’t work right.<br />
Mary Muchow:<br />
Richard Farley:<br />
Mary Muchow:<br />
Richard Farley:<br />
Mary Muchow:<br />
Richard Farley:<br />
Mary Muchow:<br />
Operator:<br />
I would pick up <strong>the</strong> phone and call that physician and ask <strong>the</strong>m for that<br />
information. If that physician is referring patients to your office and doing<br />
business with you, <strong>the</strong>n he or she should be providing that information for you<br />
or make it readily available for you.<br />
OK. I don’t want to say <strong>the</strong>ir name but it’s like McDonalds kind of name where<br />
– do you put a space between <strong>the</strong> C and <strong>the</strong> D or do you not And it’s really<br />
hard sometimes so if you could find where <strong>the</strong> official list is because we found<br />
several lists in <strong>Medicare</strong> and NPPES. Is it with <strong>the</strong> space, without <strong>the</strong> space,<br />
with <strong>the</strong> period, without <strong>the</strong> period<br />
Unfortunately, a lot of that is going to depend on how <strong>the</strong>y fill out <strong>the</strong><br />
paperwork when <strong>the</strong>y request <strong>the</strong>ir National Provider Identifier. The NPI<br />
contractor does have a searchable database. But again, depending on how<br />
that individual or healthcare provider or entity has gone to <strong>the</strong> NPI contractor<br />
and filled out paperwork and how, someone from that contractor indeed<br />
entered it into <strong>the</strong>ir database it might vary. The best bet is to go to that<br />
provider that you’re doing business with and ask <strong>the</strong>m for <strong>the</strong>ir NPI. Tell <strong>the</strong>m<br />
that you need that information to support <strong>the</strong> claim for <strong>the</strong> service that <strong>the</strong>y<br />
referred to your office.<br />
OK. Yes, I mean, we have <strong>the</strong> NPI. It’s just that you also have to put in <strong>the</strong><br />
name just right. But in any event, OK, we’ll look for that.<br />
Well, on <strong>the</strong> claim form, it’s going to be driven by <strong>the</strong> NPI that you entered<br />
into <strong>the</strong> appropriate item number on a paper claim or <strong>the</strong> corresponding<br />
electronic field for an electronic formatted claim.<br />
OK. Thanks.<br />
You’re welcome.<br />
Your next question comes from <strong>the</strong> line of Colleen Kelleher.<br />
Colleen Kelleher: Hi, I have just one question. Are remittance advices sent to providers who do<br />
not accept assignment and if so, how often<br />
Mary Muchow:<br />
We’re going to follow up on that one, Colleen. If you can give your telephone<br />
number, please.<br />
Colleen Kelleher: Sure. Area code (515) 226-7423. I have asked this at customer service and<br />
I’ve received conflicting information, so I’d just like <strong>the</strong> straight answer.<br />
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Mary Muchow:<br />
Colleen Kelleher: Thank you.<br />
OK. We will indeed follow up on that, Colleen.<br />
http://www.wpsmedicare.com<br />
Operator:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Cathy Smith:<br />
Mary Muchow:<br />
Operator:<br />
Mary Muchow:<br />
Operator:<br />
Mary Muchow:<br />
You have a follow up question from <strong>the</strong> line of Cathy Smith.<br />
Hello. I had asked <strong>the</strong> question earlier about take-backs and I do have a remit<br />
in front of me now. I just wanted to follow up on one more question. This<br />
particular one only has a provider adjustment amount and <strong>the</strong>n we do have<br />
<strong>the</strong> FB for <strong>the</strong> forwarding balance. However, <strong>the</strong>re’s also mention in <strong>the</strong> remit<br />
on <strong>the</strong> bottom of this remit, something that I’m not familiar with, <strong>the</strong> PLB04<br />
and PLB03. Can you explain what that is I’m not familiar with that.<br />
I can explain what a forwarding balance is. We will get that out of <strong>the</strong> way<br />
first. The forwarding balance…<br />
I understand <strong>the</strong> forwarding balance. I’m just unsure about a negative value<br />
with PLB04 or PLB03.<br />
Is <strong>the</strong> forwarding balance amount <strong>the</strong> same as <strong>the</strong> negative that you’re<br />
seeing of <strong>the</strong> PLB03 or 04<br />
So that’s what I’m not familiar with. I just am not familiar with that, <strong>the</strong> PLB04<br />
and 03 what that means. Is it <strong>the</strong> same as <strong>the</strong> forwarding balance<br />
Based on <strong>the</strong> recommendations made in <strong>the</strong> room, <strong>the</strong>y’re suggesting that<br />
you would call customer service and <strong>the</strong>y would be able to provide that<br />
information when <strong>the</strong>y pull up <strong>the</strong> claim information.<br />
OK.<br />
So give <strong>the</strong>m a call, <strong>the</strong>y’ll be happy to help you.<br />
OK. So is <strong>the</strong>re a particular number if we got questions on take-backs on <strong>the</strong><br />
remit or do we just call <strong>the</strong> regular customer service line<br />
It would be <strong>the</strong> regular toll-free customer service line for providers.<br />
OK, thank you.<br />
You’re welcome.<br />
And <strong>the</strong>re are no fur<strong>the</strong>r questions at this time.<br />
OK.<br />
Excuse me; you have a question from <strong>the</strong> line of Janine Hone.<br />
Hi, Janine.<br />
23
Janine Hone:<br />
Hello. In <strong>the</strong> CPT manual under <strong>the</strong> inpatient hospital care, it says, “when <strong>the</strong><br />
patient is admitted http://www.wpsmedicare.com<br />
to <strong>the</strong> hospital as an inpatient in <strong>the</strong> course of an<br />
encounter in ano<strong>the</strong>r site of service, for example, hospital emergency<br />
department, all evaluation and management services provided by that<br />
physician in conjunction with that admission are considered part of <strong>the</strong> initial<br />
hospital care when performed on <strong>the</strong> same date as <strong>the</strong> admission.”<br />
Now that seems pretty clear cut, but if I have one doctor in ER and ano<strong>the</strong>r<br />
doctor doing <strong>the</strong> admission, I bill for both of <strong>the</strong>m. What my question would<br />
be is if I have a mid-level provider, so I have a physician assistant in <strong>the</strong><br />
emergency room who is supervised by a doctor who <strong>the</strong> patient’s care is<br />
transferred to, would <strong>the</strong> physician on <strong>the</strong> acute care side be able to bill for<br />
<strong>the</strong> acute care admission, <strong>the</strong> 99222, and <strong>the</strong> emergency room care mid-level<br />
provider be able to bill under <strong>the</strong> (993) for that<br />
Brett:<br />
Janine Hone:<br />
Brett:<br />
Janine Hone:<br />
Brett:<br />
Janine Hone:<br />
Brett:<br />
Janine Hone:<br />
Brett:<br />
Janine Hone:<br />
Operator:<br />
Mary Muchow:<br />
This is Brett from Medical Review. Are <strong>the</strong> PA and <strong>the</strong> doctor both under <strong>the</strong><br />
same tax ID for group<br />
Yes.<br />
OK. Generally that would be considered <strong>the</strong> same physician because of <strong>the</strong><br />
example that if I have doctors from <strong>the</strong> same group and doctor A of <strong>the</strong> same<br />
specialty sees <strong>the</strong> patient in <strong>the</strong> morning and <strong>the</strong>n doctor B follows up in <strong>the</strong><br />
afternoon, those two services are combined for one service that day.<br />
OK. So even though it says by that physician, it’s not meaning that physician.<br />
It’s meaning <strong>the</strong> same physician group.<br />
Yes. Same group, same specialty and generally, if that PA is being<br />
supervised, that’s usually in <strong>the</strong> same group.<br />
OK and so if <strong>the</strong>y are two different doctors, if <strong>the</strong>y’re in <strong>the</strong> same group, it<br />
really doesn’t matter ei<strong>the</strong>r<br />
Same group, same specialty.<br />
Same group, same specialty. OK.<br />
Yes.<br />
All right, thank you.<br />
And <strong>the</strong>re are no fur<strong>the</strong>r questions at this time.<br />
All right. Thank you, Angie. Before adjourning this call today, I’d just like to<br />
remind all of you that have taken your valuable time today, if you could<br />
please consider completing your ForeSee website satisfaction survey that<br />
does pop up when you’re out on <strong>the</strong> website. I know we talked a lot during<br />
this call today about all of <strong>the</strong> great information that you can find out on <strong>the</strong><br />
website.<br />
24
We are very interested in your feedback on what is out on <strong>the</strong> website, what<br />
you think should http://www.wpsmedicare.com<br />
be out on <strong>the</strong> website, kinds of improvements you suggest.<br />
So if you would, please take some time to fill out that survey. Be specific in<br />
your evaluation of <strong>the</strong> website. If <strong>the</strong>re’s something you feel is valuable, let us<br />
know. Also, if you could all mention <strong>the</strong> specific tool or <strong>the</strong> web page that<br />
you’re making recommendations to, that would be very, very greatly<br />
appreciated.<br />
<strong>WPS</strong> and CMS do review <strong>the</strong> results of those surveys on a regular basis. And<br />
your feedback really does directly influence <strong>the</strong> layout, <strong>the</strong> look and feel, <strong>the</strong><br />
content, and o<strong>the</strong>r aspects of our <strong>WPS</strong> <strong>Medicare</strong> website.<br />
Once again, I’d like to thank all of you for participating today in this<br />
teleconference. I’d like to thank my colleagues here at <strong>WPS</strong> <strong>Medicare</strong> for<br />
<strong>the</strong>ir input and feedback as well and since <strong>the</strong>re are no o<strong>the</strong>r fur<strong>the</strong>r<br />
questions at this time, this will <strong>the</strong>n end our <strong>ACT</strong> today. I’m sorry, someone<br />
spoke up.<br />
Dr. Boren:<br />
Mary Muchow:<br />
Dr. Boren:<br />
Mary Muchow:<br />
Right, Mary, Dr. Boren. One quick thing for Natalie, I have sent an e-mail to a<br />
cardiologist medical director for his opinion on her question.<br />
Sorry, thanks, Dr. Boren.<br />
OK.<br />
We have Natalie’s phone number so we will be following up <strong>the</strong>n with a<br />
telephone call to her when we receive that response. All right.<br />
On behalf of <strong>Medicare</strong> Part B Provider Outreach and Education and all of <strong>the</strong><br />
<strong>WPS</strong> <strong>Medicare</strong> staff joining me and participating in this call today, I wish each<br />
and every one of you a pleasant afternoon. Thank you very much. Good bye.<br />
Operator:<br />
This concludes today’s conference call. You may now disconnect.<br />
END<br />
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